Abstract
Introduction. Value creation can begin through a joint development process. Value creation not only relies on interactions between group members but also requires studying other attributes. This study aimed to explain the experiences of nursing managers regarding value creation in nursing. Methods. A descriptive content analysis approach was used in this study. Sampling was done purposefully from April to December 2022 among the nursing managers working in Birjand educational hospitals who were willing to participate in the study. Data were collected through unstructured interviews. Graneheim and Lundman’s (2020) qualitative content analysis method was used to analyze the data, and four Lincoln and Guba criteria were used for the data rigor process. All interviews were recorded, typed in a Word file, and entered into MAXQDA (2020). Twenty-two interviews were conducted with nineteen participants. Results. In this study, eleven participants were female, and eight were male. They were employed at three different management levels, including head nurses, supervisors, and matrons. The data analysis has resulted in the identification of ten distinguished subcategories, which have been grouped into four categories based on their similarities. These four categories are concerned with value-seeking, purposeful identification of values, determining strategies to grow values, and perpetuation of values. Conclusion. By prioritizing value creation and emphasizing its importance, nursing managers can effectively improve patient outcomes and enhance the overall quality of care provided in healthcare organizations. Additionally, nursing managers play a crucial role in facilitating and maintaining values in the organization by contextualizing opportunities for the flourishing of value and directing them towards valuable benefits. Therefore, it is essential that nursing managers have a correct understanding of nursing values and value creation in nursing practice.
1. Introduction
Values are important to human function and survival [1]. Value can be made in different scopes at different times. Different value creation scopes constitute different value creation patterns. Value creation is never clearly defined, but the concept that all parties such as customers, equipment, and institutes have equal tangible value makes it an inclusive process [2]. Value often derives from the customer experience rather than other tools [3]. Recent research has widely emphasized that value stems from mutual interaction between clients and service providers [4, 5].
Value co-creation is defined as common cooperation by parties involved in direct interaction with the aim of contributing to the value creation for one or both parties [3]. Value creation can begin through a joint development process [2]. Value creation consists of three dimensions. (1) The institute acts independently and promotes value creation for clients. (2) Clients act independently, experience resources, and create value for themselves. (3) Institute and clients act together in a harmonic and interactive process that creates value for the patient as well as the institute [3].
The notion of value creation is widespread in industrial services, and they mainly seek to create economic value and obtain economic returns. However, its application in healthcare is in the theoretical and experimental stages [6, 7]. As value-based healthcare primarily aims to improve a patient’s health outcomes; any definition of it that solely emphasizes cost reduction is insufficient. While cost reduction is indeed significant, it alone cannot actualize the objective of value-based healthcare which is focused on increasing health outcomes [8]. Also, the ability to recognize distinguished nursing care, as well as the optimal level of care, will be critical factors in achieving better worth within the healthcare system [6, 7].
To create a healthcare system that really serves patients, organizations must prioritize patient focus as a basic principle. This means shifting their focus from internal processes to value creation that prioritizes the needs of patients [9]. Value creation is deemed essential from an organizational outlook, as it can increase the quality of services offered. According to Van der Cingel and Brouwer [10], incorporating nursing values into daily practice can prevent voluntary turnover and is highly valuable [10]. Unfortunately, the crucial role that nurses play as facilitators of value creation for both patients and healthcare systems is often neglected [11].
Value creation not only relies on interactions between group members but also requires studying other attributes. Service encounters, patient and staff beliefs and perceptions, and the social context of their partnerships are integral to value creation [12]. The context in which the service takes place forms the interaction between the nurse-patient and how the nurse accesses the patient’s resources. Nurses assess, interpret, and perceive patients’ behavior and resources [13]. Understanding the employee value creation process is highlighted as a critical requirement for value creation [14]. This understanding is critical for doctors and nurses, the frontline personnel who create value every day. Research on the value creation framework in nursing is limited [15], and few studies have focused on personnel perspectives on value creation behavior [12, 16].
The purposeful endeavor to create and maintain the values of organizational and professional value is growing among researchers. How frontline professionals engage with values while implementing management practices in organizations is discussible [17]. Nursing managers play a crucial role in creating value for the healthcare system, both as a structural component of healthcare delivery and as pioneers who introduce new strategies to improve processes and create a better organizational atmosphere for delivering healthcare services [18]. Nursing managers often interact closely with patients and the organization as a whole. Thus, the insights, feelings, and experiences of this group can contribute to a deeper understanding of value creation process. As far as we searched, no qualitative study was found that explained the process of value creation in nursing. Therefore, this study aimed to explain the understanding of nursing managers regarding value creation in nursing.
2. Methods
2.1. Design
We apply descriptive qualitative content analysis to explain the experiences of nursing managers regarding value creation in nursing. Qualitative content analysis is currently available for analyzing data and interpreting its meaning as a research process [19].
2.2. Data Collection and Analysis
2.2.1. Recruitment
Nurse managers willing to participate in this study were selected through purposive sampling from April to December 2022. The participants were nursing managers (head nurses, supervisors, and matrons) who have worked in Birjand educational hospitals. Nursing managers were considered with a maximum variety regarding their age, gender, and work experience. The inclusion criteria include at least five years of work experience (at least two years of management experience) and an agreement to participate in the study.
The criteria for exclusion from the study entailed a reluctance to participate in the interview and a lack of trust in disclosing personal experiences. The participants were reminded that they could leave the interview at any time if they did not want to continue the interview. This study was registered by the Ethics and Research Committee of Birjand University of Medical Sciences, Birjand, Iran (IR. BUMS. REC.1401.177).
2.2.2. Data Collection
Data were collected through in-depth unstructured face to face interviews. The interviews were conducted after working hours in a quiet and private environment where the participants were comfortable for approximately 45–60 minutes (about 52 minutes). First, demographic information including, age, gender, degree of education, current position, and work experience in the ward and management was recorded.
The interview started with the main question, Please share your experience of a working day? Also, probing questions were used to acquire a more precise comprehension of participants’ experiences. Examples of probing inquiries were “What are the goals you seek to achieve through your working day?,” “Please explain more about this?,” and “What do you mean?.” Data collection was completed when all categories were fully saturated, and no new data categories were generated. All interviews were entered into MAXQDA (2020). Twenty-two interviews were conducted with nineteen participants.
2.2.3. Data Analysis
The data were analyzed through the conventional qualitative content analysis method. Qualitative content analysis is a systematic technique used to analyze qualitative data. The process of content analysis has evolved significantly, shifting from a simple method to a more interpretive approach. All analytical processes, irrespective of the approach, entail descriptions and interpretations of various degrees of abstraction and interpretation, and no descriptions are entirely devoid of interpretation [20].
In this study, we used Graneheim and Lundman method to analyze the interviews; the interviews were analyzed into five-step process: (i) transcribing the recorded interviews, (ii) repeatedly listening to the recordings while reviewing the transcripts to identify meaning units, (iii) extracting initial codes in the form of these meaning units, (iv) grouping the codes based on conceptual similarities, and (v) continuing this process throughout all the units of analysis until categories and themes emerged [20, 21].
In the initial stage of this study, the researchers identified meaning units and extracted initial codes. Upon analyzing the 43 initial codes, the codes of refraining from personal opinions, giving importance to personnel opinions, collecting opinions, and making collaborative decisions were formed, which led to the extraction of a condensed code of humility in decision making. Similarly, after scrutinizing 26 initial codes, the researchers identified creative mental stimulation as a condensed code, which included initial codes such as identifying creative individuals, brainstorming to stimulate creative thinking, and encouraging creativity. Combining these two condensed codes resulted in the extraction of a subcategory labeled “intellectual flourishing.” Furthermore, “intellectual flourishing” along with subcategories like “alignment with the treatment team” and the “use of experiences” contributed to the development of the main category of “determining strategies to facilitate and grow values.”
2.3. Rigor
Four Lincoln and Guba criteria were used for the data rigor process [19, 22]. These criteria include credibility, dependability, conformability, and transferability. The credibility of the present study was confirmed by spending time (about seven months), collecting data, and ensuring the diversity of participants of different ages and genders.
The dependability of the present study was obtained through peer checking and external experts reviewing the interview process, coding, and analysis. Conformability was ensured by members’ checks and verification of codes by participants, long-term engagement, and multiple readings of interviews.
The transferability of the present study was also established through member checks and sampling with maximum diversity. To increase transferability, participants’ characteristics and study context were explained in detail so that readers could decide whether to use the results in their desired environment. Finally, the results of the study were given to two nursing managers out of the study. They confirmed that the results of our study are close to their experiences.
3. Results
In this study, the participants were mainly female (n = 11; 57%), with a majority holding a master’s degree (n = 9; 47%). Additionally, six participants were supervisors (32%). The average professional experience of the participants was about 19.5 years, with a mean of 12.5 years of management experience (Table 1).
Upon analyzing the data, 1179 open codes, ten subcategories, and four categories were created. Four main categories include value-seeking, purposeful identification of values, determining strategies to facilitate and grow values, and stabilization and perpetuation of values (Table 2).
3.1. Value-Seeking
At this stage, nursing managers actively seek value by continuously evaluating and analyzing goals and values.
3.1.1. Developing a Value-Seeking Mindset
Developing a transformational mindset means more interaction with values-based transformations in nursing. This subcategory describes the ongoing mental review of goals and values, as well as the designing of values alongside goals.
“I have designed a set of goals for myself and remain continuously mindful of promoting nursing values such as care, ethics, and professionalism alongside these objectives (head nurse).”. . .“We have identified the values and linked them to the goals. Every value created in nursing brings with it several other hidden values. . .Like ethics modeling in nursing, which is full of values and brings values such as respect and compassion (supervisor).”
3.1.2. Seeking Value-Oriented Transformation
Nursing managers consider seeking transformation as a fundamental requirement for effecting transformation creation in nursing. They argue that nursing managers must first internalize the concept of transformation and consider it as a value in nursing. Expressions of dissatisfaction with the status quo and taking steps towards the development of nursing were expressed in this subcategory.
“I have always been averse to stagnation and constantly seek out new ideas. Within the nursing organization, we are actively looking for solutions to existing challenges, with all members contributing to our collective pursuit of transformation. Our overarching aim is to improve the nursing profession (supervisor).”
3.2. Purposeful Identification of Values
Once goals have been established and values have been assigned to them, it becomes imperative to select and incorporate relevant values in the nursing profession. Nursing managers have identified three distinct subcategories of values, namely, individual values, organizational values, and clinical values.
3.2.1. Individual Values
Under the subcategory of individual values, a wide range of ethical, professional, and human values were reported by the participants. From their experiences, the most significant values that were extracted include increasing clinical understanding and accountability.
The development of nursing understanding begins with comprehending the nursing work’s difficulties and successfully passing through the steps of nursing management. Furthermore, it is augmented by fostering a supportive atmosphere through the cohesion of nursing staff.
“In order to gain a comprehensive understanding of nursing, it is imperative that I possess prior experience working in clinical wards and undergo the necessary stages of nursing management. Only by doing so, I will be able to fully comprehend the language and perspective of nurses (head nurse).”…“Our team is dedicated to providing support for nursing staff, and we strive to maintain a supportive environment. The cohesive nature of our nursing staff fosters mutual understanding and camaraderie among team members (supervisor).”
Every human being possesses the inherent trait of accountability, which is conceptualized as an individual value. This includes upholding legal nursing practices by adhering to established laws and reinforcing professional-social responsibility.
“I was asked to manipulate a nursing document, but I explained that it was not legally feasible. As a professional nurse, I understand and uphold the importance of authenticity and integrity in people's documents and property (head nurse).”…“I personally feel accountable to my profession and community and strive towards providing safe and effective care that upholds the dignity of my profession. The recent COVID-19 epidemic demonstrated our sense of responsibility, which enhanced respect for the nursing profession (supervisor).”
3.2.2. Organizational Values
Gaining satisfaction and making valuable change were extracted from the experiences of the participants.
It appears that by gaining satisfaction in the organization, resistance to changes can be reduced. The mutual professional respect for gaining satisfaction and gaining satisfaction following the expansion of standard performance is discussed in this section.
“The satisfaction of the doctor, the satisfaction of the personnel, and the satisfaction of the patient are very important. We try to get their satisfaction with mutual respect. Encouragement can lead nurses to feel content, while standard performance can lead to patient satisfaction. Once satisfaction is obtained, resistance dwindles and it becomes easier to implement values (head nurse).”
The participants stated that clinical challenges are continually augmenting, and to overcome these predicaments, collaborative and lasting changes in nursing must be implemented. The section conveyed the notions of changing behavior with interaction, overcoming clinical problems with collaborative change, and permanent changes with the support and trust of personnel.
“ Our team engages in consultations regarding clinical problems and changes. We inform all managers and implement changes collaboratively. Suggestions are gathered and combined, and the resultant changes are implemented with complete confidence (head nurse).”
3.2.3. Clinical Values
The experiences of nursing managers have led to the identification of clinical values such as transformation in care, a culture of cooperation, and ethics as essential aspects of healthcare organizations.
Creating a caring interest and knowledge-skills synergy with evidence-based care were identified as critical components of transformation in care.
“The workload is too high and the nurse-to-patient ratio has not been properly balanced... Nurses may become fatigued and unable to provide reliable patient care...We collaborate with nurses in caring, train them, and try to adjust the nurse-patient ratio to increase interest in care (matron).”
The importance of expanding the culture of cooperation and strengthening interactions within the organization was emphasized as a valuable clinical value by the participants. Two condensed codes, including synergy of nurse-manager interaction-cooperation and creating an encouraging atmosphere of cooperation, were identified as key factors that can facilitate cooperation among personnel in nursing.
“I actively participate in work duties, including dressing wounds. This approach not only strengthens the cooperation of the staff but also serves as a stimulus for upholding other values within the organization (supervisor).”
“I encourage people who have more cooperation in the system in any way, financial or spiritual encouragement (head nurse).”
In relation to the dominance of ethics, the participants stressed the significance of seeking justice for work motivation and promoting honest nursing practices. The nursing managers acknowledged that nurses seek organizational justice and consider it as one of their lost rights.
“…Nurses often feel that their rights are disregarded within the organization, resulting in a sense of injustice. We strive to uphold the rights of both staff and patients, and our efforts serve as a source of motivation for the nursing team (head nurse).”
Nursing managers also emphasized that the acquisition of moral virtues is a professional duty, and the development of ethics in the organization is a crucial value for the nursing profession.
3.3. Determining Strategies to Facilitate and Grow Values
The third step in value creation is determining strategies such as alignment with the treatment team, intellectual flourishing, and use of experiences to facilitate and grow values.
3.3.1. Alignment with the Treatment Team
Nursing managers mentioned creating a common attitude and drawing common goals to create alignment in the treatment team and facilitate values.
In health organizations, there are managers from different disciplines, and this has caused different opinions and attitudes in the organization. Nursing managers pointed out that to create a consistent attitude in the nursing system, it is necessary to build trust and it is better for nursing managers to design common goals for the system and try to achieve them.
“We try to gain the trust of officials and personnel by establishing mutual communication and consultation regarding system issues. When trust is achieved, they accept our opinions... (head nurse).”
“…Officials should know that our attitudes and thoughts are in line with the improvement of the system and there is no conflict with their interests. We designed common goals that we strive to achieve. If we move in the same direction with predetermined and shared goals, then we can maintain our values (supervisor).”
3.3.2. Intellectual Flourishing
In this subcategory, participants mentioned creative mental stimulation and humility in decision making.
The participants expressed intellectual flourishing as a prerequisite for facilitating and developing values. They stated that getting ideas from all personnel is a solution for the development of thinking and creativity in the organization.
“... I collect and compare all the ideas by brainstorming. I have always tried to identify creative people (head nurse).”
Nursing managers were somewhat humble in decision making and did not rely on their opinions. They mentioned that they use everyone’s opinions in the decisions of the organization and considered this as a context of value growth.
“We have a team and I take everyone’s opinions on solving problems. I care about all opinions... (supervisor).”
3.3.3. Use of Experiences
Nurse managers see experienced people as a blessing in healthcare. They consider systems that focus on the transfer of experiences to be more successful. The participants believe that by transferring valuable experiences and training experienced successors in nursing, it is possible to provide the context for the growth of values.
“We share our experiences with the system and use this opportunity to transfer experience to improve patients and the system. We respect experienced staff and always tell them that their experience is valuable for the system (head nurse).”
The participants believed that the training of people with clinical experience in nursing is the need of every organization and can contribute to the advancement of the nursing profession.
“I try to place nurses with high clinical experience alongside less experienced staff, so the less experienced nurses learn and use valuable experiences. In the following years, these nurses become more experienced and this valuable cycle continues (supervisor).”
3.4. Stabilization and Perpetuation of Values
Nursing managers believe that values can be established in the nursing profession through the two processes of continuous development of values and institutionalization of values.
3.4.1. Continuous Development of Values
For the continuous development of values in the nursing profession, continuous evaluation, continuous feedback, and renewal of values seem necessary.
Creating a sense of permanent evaluation and continuous effective feedback are discussed in this section.
“I frequently conduct unplanned visits to assess performance and staff think they are constantly being evaluated. This process has reinforced and improved their behaviors, while also mentally preparing them to enhance their performance (head nurse).”
Feedback-based evaluation and renewal of values are continuously performed by nursing managers in a value-centered organization. Participants believe that continuous feedback and evaluation will identify and correct behaviors that go against the core values.
“Following every evaluation, we provide useful feedback either face-to-face or in writing and keep following up until the desired outcomes are achieved. The personnel correct their caring behavior and steps towards the goals and values. This feedback leads to the continuation and strengthening of nursing care (head nurse).”
3.5. Institutionalization of Values
The final stage in ensuring the stability and perpetuation of values within an organization is through institutionalizing these values. Nursing managers are looking for a culture in which certain values are deeply ingrained with integrated and responsive education, role modeling in nursing, and continuity of encouraging and punishing.
In the subcategory of integrated and responsive education, managers seek to create interest and sensitivity for learning and provide meta-care learning opportunities for personnel to promote learning in the organization and then institutionalize the organizational values through training.
“We often conduct training needs assessments in the organization based on personal development plans (PDP)... We plan training based on the needs and interests of people (supervisor).”
For the institutionalization of values by nursing managers, they must first be a role model of discipline and communication so that they can spread these values in the organization.
“I try to be at work before the staff so that I can warn someone who is late and he accepts my reminder and has me as his role model. Otherwise, if I am at work later than my staff, some personnel may also be late, which causes disorganization and loss of value (head nurse).”
In the communication role modeling, nursing managers consider themselves to be the pioneers in communication and try to initiate communication and make this communication mutual.
“I am a pioneer in communication and I always emphasize that it is necessary to communicate effectively with the patient so that the patient trusts us and expresses his problems. Furthermore, I strive to enhance communication among colleagues by promoting sincere and transparent interactions (matron).”
The dominance of ethics and the acquisition of moral virtues were partially mentioned in the clinical values subcategory. Nursing managers also consider the acquisition of moral virtues and moral modeling to be effective in the institutionalization of values.
Nursing managers stated that in order to institutionalize values in the field of nursing, it is necessary to carry out the process of encouraging and punishing correctly and on time.
“Following every feedback, we employ a system of either positive reinforcement or negative consequences, depending on the specific circumstances. Additionally, other individuals within the organization observe these behaviors and may adjust their own actions accordingly (supervisor).”
4. Discussion
Little research was found in the field of value creation in nursing as far as we searched. Our study seeks to address this gap by identifying several new aspects of value creation in nursing that were not emphasized in previous studies, such as value-seeking, alignment with the treatment team, intellectual flourishing, the dominance of ethics in the organization, institutionalization of values, and seeking value-oriented transformation.
Chamakiotis et al. [7] introduced three types of social values. The focus of the research is on cognitive value which involves the exchange and transmission of knowledge between different parties. With increased interaction in this area, professional values emerge over time by creating opportunities for development, followed by the emergence of epistemic values through strengthening of the knowledge base primarily via participation in research [7].
The present study proposes a four-stage process for understanding of value creation in nursing. In the first stage, the managers develop a value-seeking mindset and seek value-oriented transformation within the organization. In the second stage, they identify and select three types of value, namely, individual, organizational, and clinical values. In the third stage, they provide a context for the growth of values through strategies such as alignment with the treatment team, intellectual flourishing, and the use of experiences. Finally, in the last stage, this process is stabilized and perpetuated by continuously developing and institutionalizing values within the organization.
In their study, Ayla Kaya and Ilkay Boz (2019) indicate that professional values in different cultures are defined by different names with different priorities. They propose a professional framework consisting of personal values, nurse professional values, and care quality [23]. Additionally, Schmidt and McArthur [1] established that essential nursing values such as human dignity, integrity, altruism, and justice constitute a foundational framework guiding professional practice [1], which is consistent with our study.
This study identifies three types of values, namely, individual values, organizational values, and clinical values. The section on individual values discusses two dimensions of clinical understanding and accountability. The section on organizational values highlights the concepts of satisfaction and creating valuable changes for the organization. Lastly, the clinical values section outlines the subcategories of transformation of care, the dominance of ethics, and the expansion of cooperation culture, which share some similarities with previous studies.
Ingrid Snellman (2015) suggested that a value context is essential for effective clinical practice in nursing. Snellman identified several core nursing values, including truthfulness, compassion, advocacy, knowledge, and accountability [24]. Our study similarly identifies truthfulness, accountability, and clinical understanding as key values in nursing.
Also, Shahriari et al. [25] in a review study found 10 moral values in nurses; among them, justice, precision in care, human relations, sympathy, and honesty align with our own findings [25]. Additionally, the dominance of ethics in the organization has been proposed as a value in our study, which can promote ethical orientation of many behaviors in the organization.
The use of care with little or no benefit to the patient is a common problem. Using values that limit poor-quality care is an important step in reducing such care [26, 27]. Value-based healthcare aims to improve the patient experience, enhance population health, reduce healthcare costs, and improve the clinician experience [8]. As in our study, transformation in care was highlighted as a clinical value that is achieved by creating a caring interest and knowledge-skills synergy.
The available evidence indicates that adequate nurse staffing, effective training programs, and a supportive organizational environment are all significant factors [18]. The three aforementioned items are common with our results. In a study conducted by Weiss et al. [28] within a sizable integrated healthcare system, the authors explored the influence of nurse staffing levels on unplanned 30-day readmissions and emergency department (ED) utilization. Their findings revealed that greater nurse staffing was linked to decreased rates of both 30-day readmissions and ED usage [28]. Our study discussed the impact of excessive workload and an insufficient nurse-to-patient ratio on patient care reliability and nurse exhaustion. To minimize negative consequences and improve care standards, organizations should prioritize having adequate staffing levels.
According to Flynn et al. [29], a supportive nurse atmosphere includes aspects such as cooperation between nurses and other personnel, opportunities for involvement in decision making, continuity in patient care, access to continuing education, and competent nurse managers, which are positively associated with error reduction, high nursing care quality, and outcome improvement [29]. In our study, developing a culture of cooperation with the synergy of nurse-manager interaction-cooperation and creating an encouraging atmosphere for cooperation and involvement in decision making were argued.
According to Zhang’s [30] practical model of value co-creation, the three phases involved in this model are feedback gathering, data analysis, and process improvement. The last phase makes this model more practical [30]. As in our study, the revision and improvement of processes, behavior changes through interaction, overcoming clinical problems with collaborative change, and lasting and permanent changes with the support and trust of personnel were discussed in the part of valuable changes.
Bagdoniene’s study in 2019 highlighted the importance of various factors such as knowledge, professional thinking, information gathering, shared learning, and knowledge-seeking [16]. However, our current study only shares the common aspects of knowledge-seeking and shared learning with Bagdoniene’s study. Our study emphasizes the necessity of shared learning and responsive education for the continuity and strengthening of organizational values.
According to Matthiesen and Wilhelm [31], evaluation is a continuous process that fosters growth, change, and improvement [31]. Similarly, our study also stresses the significance of continuous evaluation and feedback to correct, improve, and ultimately institutionalize values in nursing.
4.1. Study Limitation
We identified a limitation of this study. In this study, we went to experienced nurses and maybe it shows higher age of experience and management (the mean years of experience were 19.5 years, and the mean years of management were 12.5 years).
5. Conclusion
Due to the lack of studies on value creation in nursing, it is important for researchers and practitioners to focus more on exploring this field. Additionally, it is recommended that nursing schools integrate teachings on the fundamentals and implementation of value-based healthcare into their undergraduate nursing curriculum to prepare graduates with the necessary knowledge and skills to drive the transition towards value-based healthcare in the nursing profession. By prioritizing value creation and emphasizing its importance, nursing managers can effectively improve patient outcomes and enhance the overall quality of care provided in healthcare organizations. Additionally, nursing managers play a crucial role in facilitating and maintaining values in the organization by contextualizing opportunities for the flourishing of value and directing them towards valuable benefits. Therefore, it is essential that nursing managers have a correct perception of nursing values and value creation in nursing practice.
Data Availability
The qualitative data used to support the findings of this study are available from the corresponding author upon request.
Ethical Approval
This study was registered by the Ethics and Research Committee of Birjand University of Medical Sciences, Birjand, Iran (IR. BUMS. REC.1401.177). Data anonymity and confidentiality were preserved all over the study. There were no risks related to the study and research objectives.
Consent
Nineteen participants signed an informed consent form before participating in the study.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors’ Contributions
AA was responsible for study conception and design and data collection. AA and GM were responsible for data analysis and interpretation and drafting of the article. GM was responsible for critical revision of the article. All authors have approved the final text.
Acknowledgments
The authors would like to acknowledge the research committee of Birjand university of medical sciences and all the participants who contributed to this research.